Since you already did the Sig Chg, you need to care plan appropriately. That would include anything new since his return from the hospital. Is he medicare? Need a 5day reentry? I would document all the changes in the nurses notes and in the care plans. If he improves, you can do a sig change for improvement. Also, you added that you feel the incontinece will resolve. That would not need a sig change if it did. I don't think you need another assessment. Just good followup with documentation and care planning.
Sherri
We have a resident who has been experiencing severe
bizarre behavior and has declined from a set-up in
dressing/hygiene to extensive assist. We completed a
sig. change assessment but never careplanned him since
he was admitted to the hospital. He returned and is
now his fourteenth day. Everything remained the same
but he is now incontinent of bladder at night. This is
effecting two areas toileting which is a 3/2 from 0/0
and incontince bladder a 3 from a 0. We are
careplanning him now. Do I need to do another sig
change or can I write an addendum on the IDC note:
since his return, he has been incontinent of bladder
at night. To me, this looks like one decline, although
it's effecting two areas. Once we careplan the
incontinency, does it pay to do a sig change? If it's
already carplanned? I think it may resolve soon
anyway.
All responses anticipated.
Thanx in advance.
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Jennifer RN BSN MDS Coordinator
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